When a patient dies due to doctor's mistake

As the debate rages over whether Kenya needs a new Quality of Healthcare and Patient Safety Act or should simply strengthen the existing regulatory authorities, my focus is drawn to the most important section of the Bill, Part II: Patient Rights and Safety.

Two key articles in the bill address the healthcare provider in terms of the patient’s rights and safety. Article 9 addresses the right to care by a qualified health professional. To quote the bill:

(1) Every patient has the right to quality healthcare provided by a qualified and licensed healthcare professional.

(2) In pursuance of the right to healthcare by a qualified health professional under this section, every patient has the right to healthcare—

a) from healthcare providers with qualifications verified and approved by the relevant regulatory bodies; and

b) delivered with respect for human dignity and cultural diversity.

The second section that speaks to my heart is Article 19; Patient safety and quality assurance measures. It states that:

(1) A health facility shall—

(a) implement measures to ensure patient safety and quality of healthcare in their health facility;

(b) provide healthcare services or perform a medical procedure for which the health facility or healthcare provider at the health facility is duly qualified and licensed under this Act or any other relevant laws; and

(c) adhere to the scope of practice for the healthcare providers employed or contracted in health facilities as prescribed by the Cabinet Secretary on the recommendation of the Director-General.

(2) A person who fails to comply with the provisions of this section commits an offence and shall be liable, on conviction, to a fine not exceeding fifty million shillings or to imprisonment for a term not exceeding to 10 years, or to both.

Also read: Experts call for safer care for newborns and mothers to prevent deaths

These two articles are essentially the backbone of quality healthcare and patient safety. This may be difficult to appreciate until you meet Kenneth*, a 30-year-old widow who lost his wife, Martha*, last year.

The couple was expecting their second child, a girl they had desperately wished for. Their son was five and due to large fibroids, Martha had been advised to have surgery first before she conceived again. When the doctor gave them a go-ahead, they were excited to give their son the sibling he had been asking for.

Martha was glad to have a hospital near her office, where she attended her antenatal clinics with ease because of their flexible clinic hours. Her pregnancy progressed well and she was scheduled for delivery by caesarian section due to her previous fibroid surgery.

On the scheduled surgery day, she reported to hospital promptly, escorted by her husband. He stayed with her until she was wheeled off to surgery. He then left to check up on his business before going to pick his son from school. After he had settled the boy at home, he went back to the hospital to meet his wife and newborn daughter.

When he arrived, he was shown his wife’s bed. She was sleeping with her daughter next to her in a cot. He was overwhelmed to meet his daughter but he noticed that his wife was looking rather drowsy. She told him that she needed the nurse because she could feel that she had bled through her pad, soaking the underlying bedding.

Anxious, Kenneth called the nurse, who promptly responded and found that Martha was having postpartum bleeding. She asked Kenneth to hold the baby and sit outside the ward as she called for help from the rest of the team. What happened afterwards was something that Kenneth narrates with pain.

The doctor ordered for medication for Martha and set up intravenous fluid infusions. Martha seemed to get better but within two hours, the bleeding was back. The doctor ordered another round of medications and fluids on phone as he stated that he was in surgery. He also ordered for blood for transfusion.

Kenneth had to hand the baby over to the newborn unit so he could begin calling friends and kin to come and donate blood for his wife. He was the first one to donate his own blood.

Despite the interventions, Martha did not improve and the doctor finally showed up and decided to take Martha back to theatre. Hastily, Kenneth gave consent, fearing for her life. For hours, he paced outside the operating room, with no news. After about four hours, he saw another doctor come in and joint the team in theatre. All this time, their loved ones stayed in the hospital compound waiting for news as they prayed for Martha’s safe return.

Eventually, after an hour, Martha was wheeled out of surgery and transferred to the intensive care unit. The new doctor introduced himself as an obstetrician-gynaecologist; and explained that Martha was doing poorly despite all the interventions put in place. It was simply a moment of wait and see.

Kenneth was allowed to sit with her in the unit, where he kept praying for her safe return. An hour later, the monitors started to go all crazy and a team showed up and resuscitated Martha. She was back on track for all of 40 minutes before she had another cardiac arrest that took her, leaving Kenneth aghast.

Everybody demanded answers. The hospital held a family conference the next day but Kenneth was not satisfied. He took legal action against the institution and the doctors.

Shortcoming

Investigations revealed a fundamental shortcoming. The doctor who took Martha to surgery was a young medical officer with just under a year’s experience in independent practice. The hospital did not have a resident obstetrician-gynaecologist on call either to support him.

The doctor had never encountered postpartum haemorrhage. He knew the drugs that were used but he had no idea about the dosing regimen. He did not know how to escalate care because there lacked a clear protocol of the same. Despite transfusing Martha blood, he failed to appreciate the complications of massive blood transfusion that come about with the destabilisation of the body’s physiology.

By the time he realised that he was in too deep and started calling for help, it was too late. He could not transfer the patient to another hospital because she was on the operating table with her abdomen open.

Thankfully, the obstetrician-gynaecologist responded but even after removing the bleeding uterus, it was too late for Martha. Her body was overwhelmed, her lungs were drowning form too much fluid infusion, her blood would not clot due to depletion of clotting factors, hence the surgical sites kept oozing.

Martha died simply because of a health professional’s failure to acknowledge his limitations in good time. Martha’s surgery was not an emergency, it was scheduled. As per the Kenya Medical Practitioners and Dentists’ Council’s Scope of Practice, Martha should have been operated by an obstetrician-gynaecologist from the start. The medical officer is only eligible to operate on emergency cases with the oversight of the gynaecologist.
Article 19(1)(c) expressly holds the hospital to account to ensure their staff work within their prescribed scope of practice. However, even with the punitive fines, it is not enough to just hold the health facility to account, we must also hold the individual practitioners to account to be disciplined enough to practise within their scope. 

This has nothing to do with designation, it is all about quality of care for the patient.
When it comes to quality of healthcare and patient safety, the patient is KING!

The writer is a gynaecologist/obstetrician